Va Form 10 0103

VA FORM FEB 2005 R 10-0103 Page 1 of 2 IMPROVEMENT AND STRUCTURAL ALTERATIONS CONTINUED SECTION II - FOR VA USE ONLY HISA COMMITTEE ACTION HOME IMPROVEMENT AND STRUCTURAL ALTERATION IS NECESSARY TO ASSURE THE CONTINUATION OF TREATMENT OF APPLICANT S DISABILITY Specify the disability for which the home improvement or structural alteration is necessary or appropriate TO PROVIDE ACCESS TO THE HOME OR TO ESSENTIAL LAVATORY AND SANITARY FACILITIES FOR TREATMENT OF A SERVICE-CONNECTED DISABILITY A NONSERVICE-CONNECTED DISABILITY OF A VETERAN RECEIVING AUTHORIZED POST-HOSPITAL CARE TREATMENT A VETERAN IN RECEIPT OF AID AND ATTENDANCE OR HOUSEBOUND BENEFITS THE WORK TO BE PERFORMED IS ROUTINE MINOR WORK THAT DOES NOT CONSTITUTE A STRUCTURAL ALTERATION OR HOME IMPROVEMENT AND IS NOT CHARGEABLE AGAINST COST LIMITATION. OR APPROPRIATE FOR EFFECTIVE AND ECONOMICAL TREATMENT OF A DISABILITY. OMB Approval No* 2900-0188 Estimated Burden Avg. 5 min* VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Improvement and Structural Alterations INSTRUCTIONS SUBMIT THIS APPLICATION TO THE VA HEALTH CARE FACILITY NEAREST THE VETERANS HOME* PRIVACY ACT INFORMATION The information requested on this form is solicited under authority of Title 38 U*S*C. Veterans Benefits and will be used to determine your eligibility/entitlement and reimbursement of individual claims for home improvement and structural alterations and identify your medical records. Additional information may be solicited during the course of processing your application* The information you supply may also be disclosed outside the VA as permitted by law or as stated in the Notices of Systems of VA Records 24VA136 published in the Federal Register. Disclosure is voluntary however failure to furnish the information will result in our inability to process your request promptly and serve your medical needs. Failure to furnish the information will have no adverse effect on any other benefits to which you may be entitled* The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 5 minutes. This includes the time it will take to read instructions gather the necessary facts and fill out the form* SECTION I - VETERANS APPLICATION To be completed by Veteran HAVE YOU MADE PREVIOUS APPLICATION FOR HOME IMPROVEMENTS AND STRUCTURAL ALTERATIONS HISA NO YES If Yes give date and time mm/dd/yyyy 1. NAME OF VETERAN Last First MI This is a mandatory field. 2. VETERAN S SOCIAL SECURITY NO. 4. ADDRESS Number and Street or Rural Route City or P. O. State and ZIP Code 5. TELEPHONE NUMBER OF VETERAN Include Area Code This is a mandatory field. 3. VA FILE NUMBER 6. LOCATION OF VA REGIONAL OFFICE THAT HAS YOUR CLAIM FILE 8. SERVICE SERIAL NUMBER 7.